The role of supplementary environmental surveillance to complement acute flaccid paralysis surveillance for wild poliovirus in Pakistan - 2011-2013

Background

More than 99% of poliovirus infections are non-paralytic and therefore, not detected by acute flaccid paralysis (AFP) surveillance. Environmental surveillance (ES) can detect circulating polioviruses from sewage without relying on clinical presentation. With extensive ES and continued circulation of polioviruses, Pakistan presents a unique opportunity to quantify the impact of ES as a supplement to AFP surveillance on overall completeness and timeliness of poliovirus detection.

Methods

Genetic, geographic and temporal data were obtained for all wild poliovirus (WPV) isolates detected in Pakistan from January 2011 through December 2013. We used viral genetics to assess gaps in AFP surveillance and ES as measured by detection of ‘orphan viruses’ (≥1.5% different in VP1 capsid nucleotide sequence). We compared preceding detection of closely related circulating isolates (≥99% identity) detected by AFP surveillance or ES to determine which surveillance system first detected circulation before the presentation of each polio case.

Findings

A total of 1,127 WPV isolates were detected by AFP surveillance and ES in Pakistan from 2011–2013. AFP surveillance and ES combined exhibited fewer gaps (i.e., % orphan viruses) in detection than AFP surveillance alone (3.3% vs. 7.7%, respectively). ES detected circulation before AFP surveillance in nearly 60% of polio cases (200 of 346). For polio cases reported from provinces conducting ES, ES detected circulation nearly four months sooner on average (117.6 days) than did AFP surveillance.

Interpretation

Our findings suggest ES in Pakistan is providing earlier, more sensitive detection of wild polioviruses than AFP surveillance alone. Overall, targeted ES through strategic selection of sites has important implications in the eradication endgame strategy.

Analysis of acute flaccid paralysis surveillance in Ethiopia, 2005-2015: progress and challenges

INTRODUCTION

Ethiopia joined the global effort to eradicate polio in 1996, and interrupted indigenous wild poliovirus transmission by December 2001. However, the country experienced numerous separate importations during 2003-2013. Sensitive Acute Flaccid (AFP) surveillance is critical to rule out undetected circulation of WPV and VDPVs.

METHODS

In this study described, we used a retrospective descriptive study design to characterize the surveillance performance from 2005 to 2015.

RESULTS

The none-polio AFP rate improved from 2.6/100,000 children <15 years old in 2005 to 3.1 in 2015, while stool adequacy has also improved from 78.5% in 2005 to 92 % in 2015. At the national level, most AFP surveillance performance indicators are achieved and maintained over the years, however, AFP surveillance performance at sub-national level varies greatly particularly in pastoralist regions. In addition, the minimum standard for non-polio enterovirus isolation rate (10%) was not achieved except in 2007 and 2009. Nevertheless, the proportion of cases investigated within 2 days of notification and the proportion of specimens arriving in good condition within 3 days to the laboratory were maintained throughout all the years reviewed.

CONCLUSION

We found that the AFP surveillance system was efficient and progressively improved over the past 10 years in Ethiopia. However, the subnational AFP surveillance performance varies and were not maintained, particularly in pastoralist regions, and the non-polio enterovirus isolation rate declined since 2010. We recommend the institution of community-based surveillance in pastoralist regions and conduct detail review of the laboratory sensitivity and the reverse cold chain system.

Faster Detection of Poliomyelitis Outbreaks to Support Polio Eradication

As the global eradication of poliomyelitis approaches the final stages, prompt detection of new outbreaks is critical to enable a fast and effective outbreak response. Surveillance relies on reporting of acute flaccid paralysis (AFP) cases and laboratory confirmation through isolation of poliovirus from stool. However, delayed sample collection and testing can delay outbreak detection. We investigated whether weekly testing for clusters of AFP by location and time, using the Kulldorff scan statistic, could provide an early warning for outbreaks in 20 countries. A mixed-effects regression model was used to predict background rates of nonpolio AFP at the district level. In Tajikistan and Congo, testing for AFP clusters would have resulted in an outbreak warning 39 and 11 days, respectively, before official confirmation of large outbreaks. This method has relatively high specificity and could be integrated into the current polio information system to support rapid outbreak response activities.

Assay for identification of heterozygous single-nucleotide polymorphism (Ala67Thr) in human poliovirus receptor gene

BACKGROUND & OBJECTIVES

It is important to understand the role of cell surface receptors in susceptibility to infectious diseases. CD155 a member of the immunoglobulin super family, serves as the poliovirus receptor (PVR). Heterozygous (Ala67Thr) polymorphism in CD155 has been suggested as a risk factor for paralytic outcome of poliovirus infection. The present study pertains to the development of a screening test to detect the single nucleotide (SNP) polymorphism in the CD155 gene.

METHODS

New primers were designed for PCR, sequencing and SNP analysis of Exon2 of CD155 gene. DNAs extracted from either whole blood (n=75) or cells from oral cavity (n=75) were used for standardization and validation of the SNP assay. DNA sequencing was used as the gold standard method.

RESULTS

A new SNP assay for detection of heterozygous Ala67Thr genotype was developed and validated by testing 150 DNA samples. Heterozygous CD155 was detected in 27.33 per cent (41/150) of DNA samples tested by both SNP detection assay and sequencing.

INTERPRETATION & CONCLUSIONS

The SNP detection assay was successfully developed for identification of Ala67Thr polymorphism in human PVR/CD155 gene. The SNP assay will be useful for large scale screening of DNA samples.

Polio Eradication Initiative in India: Deconstructing the GPEI

The Global Polio Eradication Initiative (GPEI) promised eradication of polio by the year 2000 and certification of eradication by 2005. The first deadline is already a matter of history. With the reporting of polio cases in 2004, the new deadline for polio eradication by 2004 is postponed further. This article seeks to argue that the scientific and technical bodies spearheading the GPEI, including the WHO, UNICEF, and the U.S. Centers for Disease Control, have formulated a conceptually flawed strategy and that it is not weak political will that is the central obstacle in this final push for global eradication. The validity of the claims of “near success” by the proponents of the GPEI is also examined in detail. By taking India as a case study, the authors examine the achievements of the GPEI in nine years of intense effort since 1995. They conclude that the GPEI is yet another exercise in mismanaging the health priorities and programs in developing countries in the era of globalization.

Who presents to our electroneurophysiology laboratory?

OBJECTIVE

To determine the distribution rate of Electroneuromyography diagnosis and correspondence between the preliminary diagnosis and final outcome.

METHODS

The retrospective study was conducted at the Department of Neurology, Harran University, Sanliurfa, Turkey, and comprised record of patients diagnosed with Electroneuromyography during a 24-month period from April 2011 to April 2013. SPSS 11.5 was used for data analysis.

RESULTS

Of the 4,230 cases reviewed, 1,946 (46%) showed normal Electroneuromyography findings despite pathological Electroneuromyography findings in 2,284(54%) cases. The most common diagnosis was carpal tunnel syndrome in 721(17%) patients, followed by polyneuropathy 312(7.4%), peripheral nerve injury 238(5.6%), brachial plexus lesion 180(4.3%), myopathy 114(2.7%), lumbar radiculopathy 108(2.6%), poliomyelitis 62(1.5%) and injection neuropathy 62(1.5%).

CONCLUSIONS

Off-label use of Electroneuromyography may be reduced by using electroneurophysiological laboratory rotation as well as adequate and comprehensive clinical evaluation of patients.

Modeling undetected live poliovirus circulation after apparent interruption of transmission: implications for surveillance and vaccination

BACKGROUND

Most poliovirus infections occur with no symptoms and this leads to the possibility of silent circulation, which complicates the confirmation of global goals to permanently end poliovirus transmission. Previous simple models based on hypothetical populations assumed perfect detection of symptomatic cases and suggested the need to observe no paralytic cases from wild polioviruses (WPVs) for approximately 3-4 years to achieve 95% confidence about eradication, but the complexities in real populations and the imperfect nature of surveillance require consideration.

METHODS

We revisit the probability of undetected poliovirus circulation using a more comprehensive model that reflects the conditions in a number of places with different characteristics related to WPV transmission, and we model the actual environmental WPV detection that occurred in Israel in 2013. We consider the analogous potential for undetected transmission of circulating vaccine-derived polioviruses. The model explicitly accounts for the impact of different vaccination activities before and after the last detected case of paralytic polio, different levels of surveillance, variability in transmissibility and neurovirulence among serotypes, and the possibility of asymptomatic participation in transmission by previously-vaccinated or infected individuals.

RESULTS

We find that prolonged circulation in the absence of cases and thus undetectable by case-based surveillance may occur if vaccination keeps population immunity close to but not over the threshold required for the interruption of transmission, as may occur in northwestern Nigeria for serotype 2 circulating vaccine-derived poliovirus in the event of insufficient tOPV use. Participation of IPV-vaccinated individuals in asymptomatic fecal-oral transmission may also contribute to extended transmission undetectable by case-based surveillance, as occurred in Israel. We also find that gaps or quality issues in surveillance could significantly reduce confidence about actual disruption. Maintaining high population immunity and high-quality surveillance for several years after the last detected polio cases will remain critical elements of the polio end game.

CONCLUSIONS

Countries will need to maintain vigilance in their surveillance for polioviruses and recognize that their risks of undetected circulation may differ as a function of their efforts to manage population immunity and to identify cases or circulating live polioviruses.

Modeling undetected live poliovirus circulation after apparent interruption of transmission: implications for surveillance and vaccination

BACKGROUND

Most poliovirus infections occur with no symptoms and this leads to the possibility of silent circulation, which complicates the confirmation of global goals to permanently end poliovirus transmission. Previous simple models based on hypothetical populations assumed perfect detection of symptomatic cases and suggested the need to observe no paralytic cases from wild polioviruses (WPVs) for approximately 3-4 years to achieve 95% confidence about eradication, but the complexities in real populations and the imperfect nature of surveillance require consideration.

METHODS

We revisit the probability of undetected poliovirus circulation using a more comprehensive model that reflects the conditions in a number of places with different characteristics related to WPV transmission, and we model the actual environmental WPV detection that occurred in Israel in 2013. We consider the analogous potential for undetected transmission of circulating vaccine-derived polioviruses. The model explicitly accounts for the impact of different vaccination activities before and after the last detected case of paralytic polio, different levels of surveillance, variability in transmissibility and neurovirulence among serotypes, and the possibility of asymptomatic participation in transmission by previously-vaccinated or infected individuals.

RESULTS

We find that prolonged circulation in the absence of cases and thus undetectable by case-based surveillance may occur if vaccination keeps population immunity close to but not over the threshold required for the interruption of transmission, as may occur in northwestern Nigeria for serotype 2 circulating vaccine-derived poliovirus in the event of insufficient tOPV use. Participation of IPV-vaccinated individuals in asymptomatic fecal-oral transmission may also contribute to extended transmission undetectable by case-based surveillance, as occurred in Israel. We also find that gaps or quality issues in surveillance could significantly reduce confidence about actual disruption. Maintaining high population immunity and high-quality surveillance for several years after the last detected polio cases will remain critical elements of the polio end game.

CONCLUSIONS

Countries will need to maintain vigilance in their surveillance for polioviruses and recognize that their risks of undetected circulation may differ as a function of their efforts to manage population immunity and to identify cases or circulating live polioviruses.

[Polio, the long walk to the endgame]

Although the WHO original target date for the global eradication of poliomyelitis was the year 2000 -thanks to vaccination and institutional, public and private, resources for that purpose-, in 2013 the disease remained endemic in three countries, Afghanistan, Pakistan and Nigeria, and some cases were described in five others. The circulation of wild type 1 poliovirus in Israel, Gaza and the West Bank and the cases in Syria were a wakeup call, as at that time there were polioviruses derived from the oral vaccine that are still circulating among the human population and can cause the development of the disease. Travelling "from" and "to" endemic areas are factors to consider in poliovirus exportation and in its spread when it reaches areas with poor immunogenicity. Wars, terrorism, intolerance, lack of culture and proliferation of anti-vaccine groups and the rise of the anti-vaccination movement are important factors in the maintenance and expansion of the virus and in the "non-vaccination" against it. Based on the international situation to date, the Emergency Committee of WHO met in May 2014 to address the problem. It is still necessary to enhance the knowledge of the disease and its agent. In the first case to perform a differential diagnosis of flaccid paralysis and to continue vaccination programs, and in the second case to keep studying and looking for the poliovirus in environmental samples, which is a model for the study of many other viruses.

[An ELISA system based on the specific class Y (IgY) antibodies from egg yolks for the quantitative determination of D-antigen in inactivated poliovirus vaccines]

The results of the construction of the first Russian ELISA system for the quantitative determination of D-antigen of 1-3 poliovirus types in the preparations of inactivated poliovirus vaccines are presented. For the first time, this kind of system is based on the use of specific antibodies of class Y (IgY) from egg yolks of immunized hens. It was shown that this ELISA system is specific, sufficiently sensitive, and can be used for quantitative determination of D-antigen of 1-3 poliovirus types in inactivated poliovirus vaccines.

Surveillance during an era of rapidly changing poliovirus epidemiology in India: the role of one vs. two stool specimens in poliovirus detection, 2000-2010

Since 2004, efforts to improve poliovirus detection have significantly increased the volume of specimen testing from acute flaccid paralysis (AFP) patients in India. One option to decrease collection and testing burden would be collecting only a single stool specimen instead of two. We investigated stool specimen sensitivity for poliovirus detection in India to estimate the contribution of the second specimen. We reviewed poliovirus isolation data for 303984 children aged <15 years with AFP during 2000-2010. Using maximum-likelihood estimation, we determined specimen sensitivity of each stool specimen, combined sensitivity of both specimens, and sensitivity added by the second specimen. Of 5184 AFP patients with poliovirus isolates, 382 (7.4%) were identified only by the second specimen. Sensitivity was 91.4% for the first specimen and 84.5% for the second specimen; the second specimen added 7.3% sensitivity, giving a combined sensitivity of 98.7%. Combined sensitivity declined, and added sensitivity increased, as the time from paralysis onset to stool collection increased (P = 0.032). The sensitivity added by the second specimen is important to detect the last chains of poliovirus transmission and to achieve certification of polio eradication. For sensitive surveillance, two stool specimens should continue to be collected from each AFP patient in India.

Enteroviruses as a possible cause of hypertension, dilated cardiomyopathy (DCM) and hypertensive heart failure (HHF) in South western Nigeria

BACKGROUND

Human enteroviruses have long been associated with various diseases of man resulting into a wide range of acute symptoms involving the cardiac and skeletal muscles, central nervous system, pancreas, skin and mucous membranes.

OBJECTIVE

To assess the role of enteroviruses in the etiology of hypertension, DCM and HHF.

METHODS

We obtained stool specimens from 70 subjects comprising 65 patients and 5 controls and isolation was carried out on RD, L20B, HEp-2C and Vero cell lines and identified by neutralization with standard antisera (RIVM). Thirty-six enteroviruses were isolated and identified to be Coxsackieviruses-B5, A9, Echoviruses 1, 6, 7, 9, 11, 12, 22, 30 and Poliovirus type 1 and 3.

RESULTS

Three most frequently occurring enterovirus serotypes which constitute 60.0% of the 30 NPEV typed and 50.0% of all the isolates were Echoviruses, Coxsackie-B5-virus and Coxsackievirus-A9. Echoviruses constituted 50.0% of all the serotypes while Coxsackieviruses-B5 and A9 accounts for the 27.8 % and 5.6% respectively. Enteroviral isolation rate was higher in age groups 51 years and above. The percentage of study subjects who had Coxsackie-B5-viruses and echoviruses was significantly (P<0.05) higher in cases of hypertension, HHF and DCM than in control subjects. Coxackie-B5-virus, Echovirus-6 and Echovirus-11 were found in both study locations.

CONCLUSION

The findings of this study showed that Enteroviruses may likely be involved in the etiology of hypertension, DCM and HHF. Further studies would therefore be necessary for the prevention and control of these diseases.

Identification and control of a poliomyelitis outbreak in Xinjiang, China

BACKGROUND

The last case of infection with wild-type poliovirus indigenous to China was reported in 1994, and China was certified as a poliomyelitis-free region in 2000. In 2011, an outbreak of infection with imported wild-type poliovirus occurred in the province of Xinjiang.

METHODS

We conducted an investigation to guide the response to the outbreak, performed sequence analysis of the poliovirus type 1 capsid protein VP1 to determine the source, and carried out serologic and coverage surveys to assess the risk of viral propagation. Surveillance for acute flaccid paralysis was intensified to enhance case ascertainment.

RESULTS

Between July 3 and October 9, 2011, investigators identified 21 cases of infection with wild-type poliovirus and 23 clinically compatible cases in southern Xinjiang. Wild-type poliovirus type 1 was isolated from 14 of 673 contacts of patients with acute flaccid paralysis (2.1%) and from 13 of 491 healthy persons who were not in contact with affected persons (2.6%). Sequence analysis implicated an imported wild-type poliovirus that originated in Pakistan as the cause of the outbreak. A public health emergency was declared in Xinjiang after the outbreak was confirmed. Surveillance for acute flaccid paralysis was enhanced, with daily reporting from all public and private hospitals. Five rounds of vaccination with live, attenuated oral poliovirus vaccine (OPV) were conducted among children and adults, and 43 million doses of OPV were administered. Trivalent OPV was used in three rounds, and monovalent OPV type 1 was used in two rounds. The outbreak was stopped 1.5 months after laboratory confirmation of the index case.

CONCLUSIONS

The 2011 outbreak in China showed that poliomyelitis-free countries remain at risk for outbreaks while the poliovirus circulates anywhere in the world. Global eradication of poliomyelitis will benefit all countries, even those that are currently free of poliomyelitis.

Acute flaccid paralysis surveillance status and community awareness in pastoralist and semi-pastoralist communities of Ethiopia

BACKGROUND

Acute flaccid paralysis (AFP) surveillance is an essential component of the polio eradication strategy. The last laboratory confirmed wild poliovirus in Ethiopia was identified in April 2008. However, the country remains at risk for re-infection because of a number of silent areas and borders with high risk countries.

OBJECTIVE

Assess AFP surveillance status and community perception on AFP/Polio in semi pastoralist and pastoralist areas.

METHODS

Community and facility based cross-sectional survey was conducted complemented by Focus Group Discussions (FGD) from March - April, 2012. The study populations included District and health center AFP surveillance focal persons, WHO surveillance officers, community and religious leaders and women who delivered in the previous one year in purposively selected districts in Core Group Polio Project Implementation areas of Ethiopia.

RESULT

Interviews with health center and district AFP surveillance focal persons revealed deficiencies in training, supervision and feedback. The performance of AFP detection varied in the study districts and knowledge about polio and AFP detection was found to be low in the study communities.

CONCLUSION

There is a need to strengthen awareness of communities through targeted information, education and communication (IEC) interventions. Regular need-based training and supportive supervision should be conducted, involving all stakeholders including religious leaders and community leaders at each step of the awareness creation process, case detection and reporting and by giving special emphasis to silent and border districts.

Knowledge of mothers on poliomyelitis and other vaccine preventable diseases and vaccination status of children in pastoralist and semi-pastoralist areas of Ethiopia

BACKGROUND

Awareness and service utilization are key to polio eradication.

OBJECTIVE

Assess the knowledge of mothers on polio and other vaccine preventable diseases, and utilization of immunization services in pastoralist and semi-pastoralist areas in Ethiopia.

METHODS

A community-based cross sectional study using a multistage cluster sampling method involving women who delivered during the previous one year was conducted.

RESULTS

A total of 600 women were interviewed. Three hundred-and-five (50.8%) women said they knew what polio was. The time to initiate polio vaccination was correctly indicated to be at birth or within 2 weeks of birth by 224 (37.4%) women. Four hundred forty five (74.2%) women said they did not know how polio is transmitted Polio birth dose (Polio 0) and Polio 3 vaccine coverage were estimated at 32% and 37% respectively. Adjusting for other factors, knowledge of when polio vaccination starts was significantly associated with having a child vaccinated for Polio 3 (OR 95% CI = 3.45 (2.33- 5.11).

CONCLUSION

Knowledge of mothers about polio is low and a little more than one third were aware of when the initial vaccine dose should be administered. Providing detailed information on polio and the recommended vaccination schedule can contribute to improve immunization and hasten polio eradication.

Cross-border wild polio virus transmission in CORE Group Polio Project areas in Ethiopia

BACKGROUND

Ethiopia interrupted indigenous polio transmission in April 2008. However, it remains at risk of reinfection because of importation of polio virus from bordering countries.

OBJECTIVES

Assess polio immunization activities and risk of wild polio virus (WPV) importation in CORE Group Polio Project (CGPP) international border areas of Ethiopia.

METHODS

The study employed key informant interviews of community volunteers (CV), health extension workers (HEWs), program coordinators, managers and other stakeholders, as well as focus group discussions (FGDs) with community and religious leaders in six border districts (woredas) located in three regions of the country. It was conducted in March and April 2012.

RESULTS

Thirty-three key informant interviews and six FGDs were conducted. Immunization coverage was reported to be low and misconceptions about causes and transmission of polio were abundant. There was extensive cross-border movement of people for various reasons and mechanisms for prevention of cross-border polio transmission was almost non existent. AFP case detection and reporting was generally low.

CONCLUSION AND RECOMMENDATIONS

Cross-border transmission of polio can occur from several frontiers. Suggestions to control cross-border polio transmission included establishing and/or strengthening cross-border collaboration with responsible counterparts in neighboring countries by using existing cross-border forums and structures to create community awareness, share information and resources, design and implement strategies for identification of children who are eligible for vaccination or suspected AFP cases. In addition districts should coordinate supplemental immunization activities to coincide with when adjacent districts in neighboring countries are carrying out similar actions.

Linking community volunteer surveillance focal persons with health extension workers on polio surveillance

BACKGROUND

Inadequate involvement of community volunteers in vaccine preventable disease surveillance and lack of uniformity in the reporting channel.

OBJECTIVE

To identify factors affecting linkage of Community Volunteers Surveillance focal Persons (CVSFP) and HEWs/Woreda Health Offices, identify feasible and acceptable solution for strong linkage and sustainable implementation of the project.

METHOD

A qualitative study based on purposive convenient sampling method involving CVs, HEW, responsible officials on Health Extension Program (HEP) and CORE Group Ethiopia Polio Partner NGO's focal persons was conducted.

RESULT

A total of 26 discussants were interviewed in the study woredas. Training of community volunteers at enrollment was not uniform. Health Extension workers and CVs plan together, visit the community together, have periodic meeting and both are supervised by the woreda health office. Community volunteers report to HEWs or woreda health office. The HEWs complain that CVs are not available as required; some are not reporting to HEWs, HEWs are not involved in the training of volunteers. Community volunteers complain distant travel to woreda and kebele to report and for meeting.

CONCLUSION

The day to day working relation, the meeting forums, woreda level monitoring and feedback mechanism shows how well the work of CVs and relation with HEWs is recognized. No standard training procedure is followed. Volunteers are used as guide; distance travel with no/inadequate incentive can reduce commitment of volunteers. Misunderstanding of HEWs about the volunteers' private/obligatory work was a factor for loose relation.

Knowledge and practice of frontline health workers (Health Extension Workers and Community Volunteer Surveillance Focal Persons) towards acute flaccid paralysis (AFP) case detection and reporting in pastoralist and semi-pastoralist areas of Ethiopia

BACKGROUND

Front line workers in pastoralist and semi pastoralist areas are expected to play a vital role in detecting cases of Acute Flaccid Paralysis.

OBJECTIVE

Assess knowledge and practice of Heath Extension Workers (HEWs) and Community Volunteer Surveillance Focal Persons (CVSFPs) on AFP case detection and reporting.

METHODS

A cross sectional survey involving 70 Health Extension Workers (HEWs) and 71 Community Volunteer Surveillance Focal Persons (CVSFPs) was conducted in 9 districts in Core Group Polio Project Implementation areas of Ethiopia from March 1-April 30, 2013. Data were entered and analyzed using SPSS version 17.

RESULTS

Thirty four HEWs (48.6%) searched for AFP cases by going from house to house, while 27 (38.6%) did not perform any function specific to AFP surveillance. Twenty (28.2%) and 7 (9.9%) of CVSFPs respectively, indicated using a case definition of AFP which included paralysis and acute paralysis. Nine (12.7%) of the CVSPF provided responses that did not include paralysis while 22 CVSFPs (31.0%) did not know the case definition of AFP. Three HEWs and 9 CVSFPs claimed to have detected and reported AFP cases. Thirty-eight (53.5%) CVSFPs had received training on community-based surveillance while 33 (46.5%) had none. Thirty nine (54.9%) of the CVSFPs reported having received supervision during the last six months, 22 (31.0%) of whom reported having received feedback.

CONCLUSION

Inadequate pertinent knowledge on AFP and inadequate training and supervision appear to be obstacles for effective AFP detection by front line health workers in the study communities.

Lightning can strike twice: an unlucky patient of neurological interest

Poliomyelitis, once a worldwide epidemic, is becoming increasingly rare owing to the introduction of the polio vaccine in the 1950s. It is estimated that the number of cases of polio has reduced by 99% since the Global Polio Eradication Initiative (GPEI) started in 1988. Amyotrophic lateral sclerosis (ALS) is another relatively uncommon condition which also affects anterior horn cells with debilitating neurological, and deadly, consequences. An unusual case of an aggressive form of ALS developing in a 72-year-old patient with paralytic poliomyelitis in childhood is presented. Her initial presentation was puzzling, and our approach to the diagnostic dilemma is discussed.

Expanding poliomyelitis and measles surveillance networks to establish surveillance for acute meningitis and encephalitis syndromes--Bangladesh, China, and India, 2006-2008

Quality surveillance is critical to the control and elimination of vaccine-preventable diseases (VPDs). A key strategy for enhancing VPD surveillance, outlined in the World Health Organization (WHO) Global Framework for Immunization Monitoring and Surveillance (GFIMS), is to expand and link existing VPD surveillance systems (particularly those developed for polio eradication and measles elimination) to include other priority VPDs. Since the launch of the Global Polio Eradication Initiative in 1988, the incidence of polio has decrease by 99% worldwide. A cornerstone of this success is a sensitive surveillance system based on the rapid and timely reporting of all acute flaccid paralysis (AFP) cases in children aged <15 years, with confirmatory diagnostic testing performed by laboratories that are part of a global network. As countries achieve polio-free status, many have expanded syndromic surveillance to include persons with rash and fever, and have built measles diagnostic capacity in existing polio reference laboratories. Acute meningitis/encephalitis syndrome (AMES) and acute encephalitis syndrome (AES) are candidates for expanded surveillance because they are most often caused by VPDs of public health importance for which confirmatory laboratory tests exist. Vaccine-preventable cases of encephalitis include approximately 68,000 Japanese encephalitis (JE) cases, resulting in 13,000-20,000 deaths each year in Asia. Moreover, although bacterial meningitis incidence in Asia is not as well-documented, pneumococcal and meningococcal meningitis outbreaks have been reported in Bangladesh and China, and the incidence of Haemophilus influenzae type b (Hib) meningitis in children aged <5 years in India has been estimated to be 7.1 per 100,000 population, similar to that in European countries before the introduction of vaccine. This report describes a prototype for expanding existing polio and measles surveillance networks in Bangladesh, China, and India to include surveillance for viral and bacterial vaccine-preventable causes of AMES and AES and presents data from 2006-2008.